WA Open Disclosure Policy: Communication and Disclosure Requirements for Health Professionals Working in Western Australia

A. INTRODUCTION

The Western Australian Council for Safety and Quality in Health Care has worked in partnership with the Department of Health to develop the WA Open Disclosure Policy: Communication and Disclosure Requirements for Health Professionals Working in Western Australia.

Open disclosure is the ‘open discussion of an incident that results in harm (or might result in future harm) to a patient while receiving health care’.

The objectives of the WA Open Disclosure Policy are to:

• establish a standardised approach for health practitioners working in WA hospitals/health services to communicate with patients and/or their nominated relatives/carers after a clinical incident
• ensure that communication with, and support for all affected patients, relatives/carers and staff occurs in a supportive and timely manner.

Compliance with Open Disclosure procedures outlined in the WA Open Disclosure Policy: Communication and Disclosure Requirements for Health Professionals Working in Western Australia is mandatory.

All public hospitals/health services in Western Australia will either adopt the procedures outlined in the WA Open Disclosure Policy: Communication and Disclosure Requirements for Health Professionals Working in Western Australia, in toto, or as a framework for developing their own Open Disclosure procedures that meet their clinical and operational needs and available resources.

All WA public hospitals/health services practicing open disclosure will do so in accordance with the following key principles:

• Expression of regret
• Disclosure of a clinical incident to a patient
• Staff support and training
• Incompetent adults and minors support
• Patient support
• Clinical governance
• Confidentiality
• Fairness

A patient should receive an expression of regret for any harm that they have suffered as a result of a clinical incident. An apology or expression of regret must not include any admission of liability or fault.

As a matter of policy, patients must be informed of the probable or definite occurrence of a clinical incident that has resulted in, or is expected to result in, harm to the patient, including the following:

• A defined Sentinel Event that is reportable to the Director, Office of Safety and Quality in Healthcare (refer to Sentinel Event Policy for WA Health).
• A clinical incident that has or is expected to have a significant clinical effect on the patient and that is perceptible to either the patient or the health care team.
• A clinical incident that necessitates a change in the patient’s care.
• A clinical incident with a known risk of serious future health consequences, even if the likelihood of that risk is extremely small.
• A clinical incident that requires hospital/health service staff to provide treatment or undertake a procedure without the patient’s consent.

Clinical incidents, as outlined above, require initiation of the Open Disclosure Process.

A clinical incident may signal a serious breakdown in health care systems and require thorough investigation and response. If a hospital elects to undertake an investigation of a clinical incident using State qualified privilege, or under Commonwealth qualified privilege (i.e. AIMS), then no information pertaining to the investigation should be released to the patient until legal advice has been obtained.

When implementing Open Disclosure procedures at the local level, all WA public hospitals/health services will consult with RiskCover, their private insurer (where relevant), the Legal and Legislative Services Directorate of the Department of Health or the State Solicitor’s Office to ensure that:

• their open disclosure procedures meet the needs of the hospital/health service, their legal representatives and their insurers or manager of their self-insurance fund
• the operation of the WA Open Disclosure Policy at the local level does not breach any legislation, their insurance policy or self-insurance cover document
• all legal and insurance requirements are fully met.

Private Hospitals may wish to use the WA Open Disclosure Policy: Communication and Disclosure Requirements for Health Professionals Working in Western Australia as a basis for developing their own Open Disclosure Policy.

B. FURTHER INFORMATION

The WA Open Disclosure Policy: Communication and Disclosure Requirements for Health Professionals Working in Western Australia must be read and administered in conjunction with the following policies and guidelines:

• Department of Health (2007) Clinical Incident Management Policy for WA Health Services using the Advanced Incident Management System (AIMS) (2nd Edition)
• Department of Health (2008) Sentinel Event Policy (3rd Edition)
• Department of Health (2005) Clinical Risk Management Guidelines for the Western Australian Health System
• Department of Health (2006) Patient Confidentiality and Divulging Patient Information to Third Parties (Operational Circular 2050/06)
• Australian Commission on Safety and Quality in Health Care (2008). Open Disclosure Standard: A National Standard for Open Communication in Public and Private Hospitals, following an Adverse Event in Health Care

The WA Open Disclosure Policy: Communication and Disclosure Requirements for Health Professionals Working in Western Australia and associated resource materials may be accessed at the following website address: http://www.safetyandquality.health.wa.gov.au

All enquiries about the operation of Open Disclosure in WA public and private hospitals should be directed to the Office of Safety and Quality in Healthcare on (08) 9222 4080 or email: safetyandquality@health.wa.gov.au

Dr Peter Flett
DIRECTOR GENERAL
WA HEALTH

ATTACHMENTS:

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WA Open Disclosure Policy: Communication and Disclosure Requirements for Health Professionals working in Western Australia, May 2009